It’s totally fine if you don’t use Twitter. I get it, really… I recently posted a thread on Twitter that gained a little bit of traction, as well as some layperson responses and I should share it here since I felt like there were a number of succinct, helpful teaching points. The entire tweet thread is “unrolled” beneath the embedded initial tweet.

Stuff I know about bronchiolitis – a Twitter thread…

It is unequivocally a clinical diagnosis. In normal, non pandemic years a viral test/PCR is not necessary 1/n

Usually symptoms worsen at around the 4-5th day for RSV, maybe a little later for human metapneumovirus 2/n

Things start with congestion, cough, and sometimes fever – then the wheezing and increased work of breathing begin 3/n

Once the symptoms “peak” the worst of it is usually <4-5 days but overall symptoms can last 21++ days 4/n

Even during the peak symptoms vary. Sometimes kids breathe faster, noisier, quieter, more snot, less snot etc,. Trends in how a kid is doing is an important part of the history, because sometimes they look worse at home 5/n

Bronchiolitis can be scary – the biggest, “back of the mind” worry is that kids will stop breathing and/or run out of energy – fortunately that is SUPER rare, with the greatest risk of apnea age adjusted <42-44 weeks GA and congenital heart disease 6/n

Those tiny babies with bronchiolitis don’t even get to the wheezy stage sometimes – they just go apneic on days 2-3 7/n

In general I tell parents to return for RR persistently greater than 70 over the day and feeding <50% usual volume 8/n

Most babies do great with frequent suctioning – pre feeds and sleep mostly – and lots of TLC 9/n

Parents benefit from hearing about how and why their baby’s breathing fast and hard – baby chest walls have a lot of cartilage and are very compliant – retractions are easy to see. baby w bronchiolitis who is compensating approp. SHOULD incr RR and use accessory muscles 10/n

Also explain exactly WHAT is is and how it is different than bronchitis – I explain using the analogy of the lungs as an upside down tree and explain what infection at different points looks like (trunk=croup) (alveoli pus=pneumonia) 11/n

Things that don’t help on bronchiolitis – albuterol, steroids, hypertonic saline, antibiotics 12/n

High Flow may help some babies – grunting, head bobbing, severe distress but it doesn’t prevent intubation. Starting high flow early prevents you from starting it later – think about that for a moment 13/n

And 90% of children under the age of 2 will get bronchiolitis at some point – so when a baby has URI symptoms now explain or show families what bronchiolitis can look like – maybe with a video at this link – https://blog.cincinnatichildrens.org/bronchiolitis:-a-new-parents-guide-to-one-of-the-most-common-winter-illnesses 14/n

And most of all be compassionate – this is a scary illness, but most infants can get through it just fine 15/n

More stuff… cough and cold medicines don’t help. For children older than 6 to 12 months who are developmentally appropriate a spoonful of honey at night can suppress cough just as well as any over-the-counter cough medicine 16/n

Don’t over suction. The rhinorrhea is going to keep coming no matter what you do. Over suctioning can cause swelling and inflammation of the nasal passages making things worse 17/n

Discourage families from using home O2 sat monitors. Oxygen saturations are not the most important data that we should look at when assessing clinical status in children with bronchiolitis. O2 sats are not real time data, they are averaged over the last half minute. 18/n

Babies are prone to momentary drops and changes in the sats that don’t necessarily reflect clinical status. A sat of 89 in a baby that is not distressed, has good color, and is eating well, especially if it is brief is not important 19/n

Originally tweeted by Brad Sobolewski, MD, MEd (@PEMTweets) on September 16, 2021.